Tutorial 28th. August 2012.

Tutorial
Web-site
Contact us

Tonight's tutorial was on meshes and other materials in urogynae.
It was by Carolyn North and was excellent.

Tutorial 23rd. August 2012.

Tutorial
Web-site
Contact us

Tonight we had the good fortune to have a tutorial from Claire Candelier, who has recently become a part II examiner.
She discussed a number of essays she had sent out a couple of weeks ago.
She spaced out the text so that the essays would print on both sides of an A4 sheet, like the exam.
So, you'll need to scroll down to see the whole list of questions.

MRCOG PART 2

Despite being advised not to travel to Ghana, a Caucasian woman, now 20 weeks pregnant, is planning a two-week holiday there in a month’s time.

What illness-avoidance advice would you offer her?            (4 marks)

What other advice would you also offer her?              (5 marks)

What chemoprophylaxis would you recommend against malaria?  (3 marks)

One month after her return to England, she develops a flu-like illness with headaches, chills and a temperature. You suspect she has caught malaria. What are your initial investigations?                                (2 marks)                                                                                                                                         

Plasmodium falciparum malaria has been confirmed. What is your management?                                                         (4 marks)

What are the fetal risks of maternal malaria?              (2 marks)

MRCOG PART 2

A 24 year old woman attends her GP surgery. She is 14 weeks pregnant. She has had a pruritic, maculopapular rash for the past 16 hours. What is your diagnosis and your initial management?                     (2 marks)

What are the fetal risks associated with this maternal infection? (3 marks)

How would you manage the pregnancy antenatally?      (2 marks)

MRCOG PART 2

A 25 year old woman attends antenatal clinic for booking at 12 weeks of gestation.  She is known to be HIV positive and is on highly active anti-retroviral therapy (HAART). This is her first pregnancy.

What is your initial management plan, including investigations?      (8 marks)

Following screening for Down syndrome, she wishes a diagnostic test as her risk is 1 in 50. What should be discussed with her before the amniocentesis?    

(2 marks)

At 36 weeks of gestation, she is on HAART and her viral load is 20 copies per ml. What advice would you give her regarding mode of delivery?    (2 marks)

At 38 weeks of gestation, she is admitted to hospital in labour. On admission, her cervix is 4cm dilated with intact membranes and the presentation is cephalic. Her wish is for a vaginal birth. What is your care plan for her labour and delivery?                                                                  (4 marks)

What is your immediate care plan for her baby?                (3 marks)

MRCOG PART 2

A 20 year old pregnant suffers from recurrent attacks of genital herpes during her pregnancy, at 16 weeks and at 28 weeks of gestation. She self-medicates with acyclovir. At 36 weeks of gestation, she is seen in the hospital antenatal clinic. She wants a vaginal delivery but is worried about infecting her baby with herpes. What would you advise her?                                         (2 marks)

What are the transmission risks and the risks to the neonate?    (2 marks)

MRCOG PART 2

A 35 year old teacher attends antenatal clinic. She is 16 weeks of gestation and has recently been in contact with a child with slapped cheek (parvovirus). She is very anxious. What would your initial management be?             (2 marks)

The maternal B19 specific IgM level is raised with absent IgG. What is the significance of this result?                                                                  (1 mark)

What are the fetal risks?                                                                     (4 marks)

         

What is your management plan?                                                        (4 marks)

MRCOG PART 2

A woman is admitted with her breastfed baby to the postnatal ward 9 days after a home birth. Her GP has been treating her with co-amoxiclav for mastitis. Her symptoms are worsening with breast engorgement, cellulitis and worsening pain in her left breast. She has developed a swinging temperature and is now complaining of diarrhoea and vomiting.

What is your initial management?                                             (5 marks)

Blood cultures have grown GAS (streptococcus pyogenes). What infection control measures should be in place to reduce the risk of transmission?

(4 marks)

What risks are there for her baby? What measures should be implemented?

(1 mark)

What are the indications for admission of this woman to an Intensive Care Unit?                                                                                 (5 marks)

      

MRCOG PART 2

A 28 year old woman attends the pregnancy counselling clinic. She is a Para 0+1 and is wishing to conceive. She is currently using condoms for contraception. Aged 12, she was diagnosed with type 1 diabetes and takes humalog mix 50.  Her BMI is 24. There is a strong family history of hypertensive disorders.

What is your management?                                                       (marks 6)

This woman is seen after a reassuring dating scan at 12 weeks of gestation. What is your antenatal care plan?                                        (marks 6)

At 30 weeks of gestation, she is admitted to the delivery suite with a 24 hour history of persistent vomiting. She has not been aware of fetal movements for the past 12 hours. On admission, she looks unwell, dehydrated, has a temperature of 38 degrees and ketonuria. A cardiotocograph records a fetal heart rate of 165 bpm baseline, with reduced variability for the past 30 minutes.

Explain your initial management plan.                                     (marks 4)

She is reviewed in the antenatal clinic at 38 weeks of gestation. Her blood glucose profile is satisfactory. Fetal movements are normal. Serial ultrasound scans have shown a reassuring growth profile with an estimated fetal weight at 36 weeks of 3.2kg. The presentation is cephalic.

What is your care plan for mode and timing of delivery?              (marks 3)

MRCOG PART 2

A Para 0+0 woman is seen in the antenatal clinic following her dating scan at 12 weeks of gestation. She suffers from epilepsy and takes lamotrigine 100mg per day. She has been fit-free for the past 12 months. Her GP has advised her to continue her anticonvulsant medication.

What antenatal care plan would you advise?                                    (marks 3)

Are there increased risks to her pregnancy due to her epilepsy? What are the maternal and fetal complications?                                                        (marks 5)

What care plan for labour would you advise?                                  (marks 4)

 

Tutorial 20th. August 2012.

Tutorial
Web-site
Contact us

Tonight we had the good fortune to have Alex Heazell teaching.
He is an authority on FGR, stillbirth etc. and a very good teacher, so who better to talk on these subjects.

Questions for MRCOG Pt 2 Group – 20^th August 2012. Alex Heazell.

1. A woman is referred to the antenatal clinic at 28 weeks’ gestation with a symphysis fundal height measuring less than that expected for gestational age.

a) What is your initial management in the antenatal clinic? (8 marks)

b) If you suspect FGR what would ongoing management plan be? (12 marks)

2. A patient is referred to the maternity day unit at 32 weeks gestation with absent fetal movements. An ultrasound scan makes a diagnosis of intrauterine fetal death.

a) Describe your initial management (6 marks).

b) She delivers a 1.2kg male infant. Describe your ongoing management for this patient and her partner (14 marks). 

Tutorial 16th. August 2012.

Tutorial
Web-site
Contact us

Tonight's essays were:

EMQ  Cervical smear management.       

Critically evaluate current therapeutic interventions in fetal therapy.

This has not come in the essays. But I reckon it will soon: there was an article by Katie Morris et al in TOG in 2010. Volume 12, Issue 2, pages 94–102, April 2010 and another by Basude & Overton in OGRM in 2012. Volume 22, Issue 8 , Pages 223-228, August 2012.

Critically evaluate neonatal screening.

This has not come in the essays, but there have been a lot of developments. And any one who can say “medium-chain acyl-coA dehydrogenase deficiency” deserves an immediate pass in the MRCOG.

A woman with epilepsy attends for pre-pregnancy counselling.

1.      Detail the history you will obtain.              4 marks

2.      Outline the advice you will give.                                8 marks

3.      Outline the key features of the management of the pregnancy and labour.  8 marks

This came in 1999 and 2004 in the above form, but not since. It is due to make a re-appearance.

A woman of 48 is referred with erratic vaginal bleeding for six months. She has had an intra-uterine contraceptive in place for five years. She has occasional hot flushes.

1.      Justify the things you will focus on in taking her history.           6 marks

2.      Justify the investigations you will perform.     6 marks

3.      Justify the advice you will give.                          8 marks        

               

This essay came in 1998, but has not featured since. It gave a wide scatter of marks, so I reckon it will be used again.

This takes us up to 65 essays in this session.

On Monday Claire Candelier will talk about diabetes and infection in pregnancy.

I have e-mailed some questions that she will use.

If you have not received them, let me know.

The EMQ was on cervical cytology.

 

Cervical smear management.

Lead-in.

There are too many scenarios and the option list is too long. And some of the “scenarios” are really MCQs. Don’t tell me – I know! I have tried to think of all the questions that could arise. At some point I’ll chop it into several bits to make the option list more sensible. A smaller option list would also allow me to introduce more “tempters” that sound as though they should be the correct answer.

The following scenarios relate to the management of cervical smears.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

ALOs:              actinomyces-like organisms

BSCCP            British Society for Colposcopy and Cervical Pathology. http://www.bsccp.org.uk/

CIN:                 cervical intraepithelial abnormality

CGIN:             cervical glandular intraepithelial abnormality

FSRH:              Faculty of Sexual and Reproductive Health: http://www.fsrh.org/

GUM clinic:  genito-urinary medicine clinic

LBC:                 liquid-based cytology

LLETZ:             large loop excision of the transformation zone

NEC:                normal endometrial cell

NHSCSP:        NHS Cervical Screening Programme: http://www.cancerscreening.nhs.uk/cervical/

                         http://www.cancerscreening.nhs.uk/cervical/index.html

POP:               progesterone-only Pill

TZ:                   transformation zone

Option list.

a.         repeat the test

b.        repeat the test after 6 months

c.         repeat the test at 6 and 12 months

d.        repeat the test at 6 and 12 months and then annually until she has had 10 years’ follow-up followed by repeat tests at the normal intervals for her age

e.        repeat the test after 3 or 5 years according to her age as per routine follow-up

f.          repeat the test after HPV testing

g.         repeat the test after giving an appropriate antibiotic

h.        repeat the test after removing her IUCD.

i.           repeat the test after removing the IUCD and giving an appropriate antibiotic

j.          repeat the test after treating the TZ with diathermy

k.         repeat the test after treating the TZ with cryocautery

l.           discharge from follow-up

m.      refer for colposcopy

n.        refer for colposcopy within 2 weeks

o.        refer for colposcopy within 8 weeks

p.        refer for colposcopy within 12 weeks

q.        refer for colposcopy only if she has other significant signs or symptoms

r.          refer for cone biopsy

s.         refer for fractional curettage

t.          refer for “see and treat” LLETZ

u.        refer to GUM clinic

v.         recommend that she go back to America

w.       there is insufficient information to formulate a management plan

x.         false

y.         true

z.         none of the above

Scenario 1.

A woman with no previous abnormal smears has a routine smear showing an inadequate sample . What management will you suggest?

Scenario 2.

A woman with no previous abnormal smears has had a smear showing borderline nuclear changes.  What management will you suggest?

Scenario 3.

A woman with no previous abnormal smears has had a smear showing borderline nuclear changes. Cervical ectopy is noted.  What management will you suggest?

Scenario 4.

A woman with no previous abnormal smears has had a smear showing borderline cells of endocervical origin. What management will you suggest?

Scenario 5.

A woman with no previous abnormal smears has had a smear showing inflammatory changes.  What management will you suggest?

Scenario 6.

A woman with no previous abnormal smears has had a smear showing  inflammatory changes and ALOs. What management will you suggest?

Scenario 7.

A woman with no previous abnormal smears has had a smear showing  inflammatory changes. She takes the COC for contraception. What management will you suggest?

Scenario 8.

A woman with no previous abnormal smears has had a smear showing  inflammatory changes. She has a copper IUCD. What management will you suggest?

Scenario 9.

A woman with no previous abnormal smears has had a smear showing  inflammatory changes and ALOs. She has had hysteroscopic sterilisation with ESSURE. What management will you suggest?

Scenario 10

A woman with no previous abnormal smears has had a smear showing borderline changes. A repeat smear after 6 months is normal. A repeat smear after 3 years shows inflammatory changes. A repeat smear after 6 months is normal. A repeat smear after 3 years shows borderline changes. What management will you suggest?

Scenario 11

A woman with no previous abnormal smears has had a smear showing mild dyskaryosis of squamous cells. What management will you suggest?

Scenario 12

A woman with no previous abnormal smears has had a smear showing moderate dyskaryosis of squamous cells. What management will you suggest?

Scenario 13

A woman with no previous abnormal smears has had a smear showing severe dyskaryosis of squamous cells. What management will you suggest?

Scenario 14

A woman with no previous abnormal smears has had a smear suggestive invasive disease. What management will you suggest?

Scenario 15

A woman with no previous abnormal smears has had a smear showing borderline nuclear changes in glandular cells. What management will you suggest?

Scenario 16

A woman with no previous abnormal smears has had a smear showing ? glandular neoplasia. What management will you suggest?

Scenario 17.

A woman with no previous abnormal smears has had a smear showing normal endometrial cells. What management will you suggest?

Scenario 18.

A woman with no previous abnormal smears has had a smear showing atypical endometrial cells. What management will you suggest?

Scenario 19

A woman with no previous abnormal smears has had a smear with a normal result. Contact bleeding was noted when the smear was taken. What management will you suggest?

Scenario 20

An American woman with no previous abnormal smears has been used to having annual smears. She has had a smear with a normal result and requests a repeat in 12 months. What management will you suggest?

Scenario 21

A woman with no previous abnormal smears is on renal dialysis and has had a smear with a normal result. What management will you suggest?

Scenario 22

A HIV +ve woman with no previous abnormal smears has had a smear with a normal result. What management will you suggest?

Scenario 23

A woman with no previous abnormal smears has had a smear with a normal result. She smokes 20 cigarettes daily and has a long history of recurrent genital warts. What management will you suggest?

Scenario 24.

A woman of 70 presents with postmenopausal bleeding. She had smears at the recommended intervals from the age of 22. All were normal. The last was taken at the age of 64. What is your management in relation to taking a smear?

Scenario 25.

A woman of 55 presents with hot flushes since her periods stopped at the age of 54. She wishes to go on HRT and there are no contraindications. She had smears at the recommended intervals from the age of 25. All were normal. The last was taken two years ago. What is your management in relation to taking a smear?

Scenario 26.

Women who have been treated for CIN are 2 – 5 times more likely to develop cancer than women who have not been treated. True or false?

Scenario 27.

 More than 50% of women who develop cancer after treatment for CIN have been lost to follow-up. True or false?

Scenario 28.

Which of the following statements are true and which false?

a.   cone biopsy is linked to ↓risk of recurrence compared to LLETZ.

b.  excision margins that are not CIN-free ↑ the risk of recurrence, with endocervical margins that are not CIN-free posing a greater risk that similar ectocervical margins.

c.   age > 35 years increases the risk of recurrent disease.

d.  follow-up after treatment for CIN should start between 3 & 6 months from the time of treatment.

e.  the initial examination should be with colposcopy plus cytology.

f.   a failure to achieve negative results in the year after treatment means colposcopy should be done.

g.   a required standard for treatment success is that ≥ 90% of women should have no evidence of dyskaryosis in the year after treatment.

h.  a required standard for treatment success is that there should be ≤ 5% of histologically-confirmed treatment failures by 1 year after treatment.

Scenario 29

Women who have had normal follow-up results for 2 years after treatment of CIN 1 can revert to the routine recall.

Scenario 30.

Follow-up should continue with increased frequency for 5 years after treatment of CIN 2 & 3, after which recall at routine intervals is OK if all the follow-up has been normal. True or false?

Scenario 31.

A woman with LLETZ for CIN3 twelve months ago had a normal smear 6 months later. A smear taken  12 months after treatment is also normal. What management will you suggest?

Scenario 32.

A woman with LLETZ for CIN3 twelve months ago had a normal smear 6 months later. A smear taken  12 months after treatment shows mild dyskaryosis. What management will you suggest?

Scenario 33.

A woman on normal recall has hysterectomy for menorrhagia. There is no evidence of CIN on histology. What follow-up would you recommend?

Scenario 34.

A woman who was not on normal recall has hysterectomy for menorrhagia. There is no evidence of CIN on histology. What follow-up would you recommend?

Scenario 35.

Women who have had hysterectomy and require follow-up with vault smears cannot be managed within the NHSCSP. True or False?

Scenario 36.

A woman who was not on normal recall has hysterectomy for menorrhagia. There is evidence of completely excised CIN3 on histology. What follow-up would you recommend?

Scenario 37.

A woman who was not on normal recall has hysterectomy for menorrhagia. There is evidence of incompletely excised CIN3 on histology. What follow-up would you recommend?

Scenario 38.

A woman has conservative treatment for early stage cancer of the cervix. What follow-up should be recommended?

Scenario 39.

A woman is referred with severe dyskaryosis, but colposcopy is normal. What follow-up should be recommended?

Tutorial 13th. August 2012.

Tutorialhttp://soundcloud.com/drtmcf/tutorial-13-august-2012
Web-site
Contact us

Tonight we had 4 SAQs and 1 EMQ.

A woman is referred after her third consecutive miscarriage at 10 weeks.

1. outline the key features in the history you will take.                                               4 marks

2. list the main causes of recurrent miscarriage.                                                         4 marks

3. critically evaluate the investigations you will arrange.                                             6 marks

4. critically evaluate the available treatments for unexplained recurrent miscarriage.   6 marks

A girl of 15 is referred to the gynaecology clinic. She is concerned because she has not started to menstruate although all her friends have.

1. Justify the history you will take.                      6 marks

2. Justify the investigations you will arrange.       6 marks

3. Justify your management                                8 marks

You have been asked to write a protocol for the diagnosis and management of umbilical cord prolapse.

1. Justify the steps you will take.                                        6  marks

2. Justify the key advice you will include in the protocol.   14 marks

With regard to neonatal jaundice (NJ):

1.  Categorise the causes of NJ.                                                   6 marks.

2.  Outline the consequences of NJ.                                             4 marks.

3.  Justify the antenatal management of an anticipated case of NJ.  4 marks.

4.  Outline the management of a neonate with NJ.                          6 marks.  

Tutorial 9th. August 2012.

Tutorial
Web-site
Contact us
I am pleased to say we are back in business with a new mixer / amplifier allowing me to record the tutorials. The tutorial was shortened as the 9th. August is my wedding anniversary and Valerie and I had a table booked for dinner.

The topics were:

With regard to adhesions.

1.   Outline the incidence and possible adverse consequences of adhesion formation after gynaecological surgery.                                                                  8 marks.

2.   How may the incidence of surgical adhesions be reduced?  12 marks.              

A recent immigrant is seen in the gynaecology clinic six months after the delivery of a stillborn baby. She complains of continuous urinary incontinence.

1.   Outline the main themes for a comprehensive assessment.  12 marks.

2.   Outline the main issues relating to the management.               8 marks.

You have been asked to write guidance for the unit in relation to labour and delivery in water.

Outline how you will go about the task.                            8 marks.

Discuss the key issues to be included in the guidance. 12 marks

There was no EMQ.

Tutorial 6th. August 2012.

I wrote the bleak message below and today pondered if there was a solution.
The answer was obvious - perhaps I had kept copies of the previous talks.
I am pleased to say that I had.
Ahmed Yassin's talk be on the internet as the podcast from 1 November 2011.
http://soundcloud.com/drtmcf/tutorial-1-november-2011
Julie's talk will be on the internet as the podcast from 23 February 2012.
You can find it here: http://soundcloud.com/drtmcf/tutorial-23-february-2012.
I started sending all the materials for Dr. Yassin's talk, but stopped when I realised I could not record the session.
I will now send the rest, but it takes ages, so be patient.
Julie used some different questions last night to those she used before. I'll send both lots with answers.
There was also an additional question from Dhvani that was discussed last night - you'll just have to answer it yourself.
We also managed to squeeze in an EMQ.
I'll e-mail it as an attachment.
I am sorry to say that there is no podcast for tonight's tutorial.
The signal from the microphones I use needs to be processed before being fed into the computer for recording.
The processing is done by a mixer / amplifier.
The one I have has worked flawlessly for quite a while, but tonight the green light that says it is working came on and then vanished.
I tried changing the power supply, fitting batteries etc., but I could not resuscitate it.
I'll prise it open tomorrow to see if I can find out what is wrong, but I suspect that I will need to buy a new one and that is going to take some days, meaning that tomorrow's urogynaecology tutorial will also not be recorded.

Tutorial 2 August 2012

Tutorial.
Web-site.
Contact us.

Tonight we had an EMQ and 4 essay topics and still managed to finish early.
 

 PPH.

Lead-in.

The following scenarios relate to post-partum haemorrhage.

For each, select the appropriate answer.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

APH:   antepartum haemorrhage.

GTG:   Green-top Guideline No 52. “Prevention and Management of PPH.”

i.m.      intramuscularly.

PPH:   postpartum haemorrhage.

s.c.      subcutaneously.

Scenario 1.

A 34 year-old, para 4 delivers the first twin and bleeds loses 250 ml. of fresh blood. A further 300 ml. is lost after the delivery of the second baby. What is the classification of the bleeding?

Scenario 2.

A 25 year-old nulliparous woman delivers a stillborn baby at 22 weeks. 1,000 ml. of fresh bleeding occurs in the next 2 hours. What is the classification of the bleeding?

Scenario 3.

A 45 year-old primigravid woman is readmitted at 10 weeks post-delivery as she has bled continuously for 3 weeks. What is the classification of the bleeding?

Scenario 4.

A 34 year-old woman passes placental tissue and 500 ml. of fresh blood 14 weeks after delivery of her second child. What is the classification of the bleeding?

Scenario 5.

Which drug is recommended by the GTG for routine use in the active management of the 3^rd. stage?

Scenario 6.

By what amount does active management using syntometrine reduce the risk of 1ry. PPH?

Scenario 7.

What is the definition of primary PPH?

Scenario 8.

What is the definition of secondary PPH?

Option list.

Bleeding from the birth canal ≥ 500 ml.

Bleeding from the birth canal ≥ 500 ml. up to 24 hours after delivery of the placenta.

Bleeding from the birth canal ≥ 500 ml. from 24 hours after delivery of the placenta until 6 weeks later.

Bleeding from the birth canal ≥ 1,000 ml. from 24 hours after delivery of the placenta until 6 weeks later.

Bleeding from the birth canal ≥ 500 ml. from 24 hours after delivery of the baby until 12 weeks later.

Bleeding from the birth canal ≥ 1,000 ml. from 24 hours after delivery of the baby until 12 weeks later.

Abnormal bleeding from the birth canal from 24 hours after delivery of the baby until 12 weeks later.

APH.

1ry. PPH.

Major primary PPH.

2ry. PPH.

Syntocinon 5 i.u. i.m.

Syntometrine 5 mg. i.m.

Misoprostol 10 mg. orally.

Gemeprost 40 mg. rectally.

Vasopressin 5 i.u. s.c.

20%

40%

60%

80%

None of the above.

 

Essays 2 August 2012

1.      Critically evaluate the management options for uterine fibroids.

2.      Critically evaluate the non-contraceptive benefits of the combined oral contraceptive.

3.      A 32 year-old woman attends the clinic with her partner. A recent laparoscopy for pelvic pain and dyspareunia revealed endometriosis. They have not used contraception for 12 months but have not conceived. Neither has had a child before.

1.   Outline the history you will take.                                                               6 marks

2.   Outline the investigations you will arrange.                                           6 marks

3.   Outline the information you will wish to discuss with the couple.   8 marks

4.      A 32 year-old woman with learning difficulty attends the gynaecology clinic with her mother. The referral is because of severe dysmenorrhoea and menorrhagia. The mother is keen for her to have hysterectomy and is prepared to give her consent.

1.  What factors will you take into consideration before offering treatment?                 8 marks.

2.  Outline the treatment options, not including hysterectomy, that you will discuss.   6 marks.

3.  If it is concluded that hysterectomy is the best option, justify the steps you will take to

arrange this.                                                                                                                                          6 marks.